Elsevier

Journal of Affective Disorders

Volume 228, 1 March 2018, Pages 49-59
Journal of Affective Disorders

Research paper
Developing and validating a perinatal depression screening tool in Kenya blending Western criteria with local idioms: A mixed methods study

https://doi.org/10.1016/j.jad.2017.11.027Get rights and content

Highlights

  • The EPDS and PHQ-9 are valid and reliable screening tools for perinatal depression.

  • The Perinatal Depression Screening (PDEPS) is a new 9-item locally-developed tool.

  • The PDEPS blends Western psychiatric concepts and local idioms of distress.

  • Prevalence of perinatal depression in Western Kenya less than 10%.

Abstract

Background

Routine screening for perinatal depression is not common in most primary health care settings. The U.S. Preventive Services Task Force only recently updated their recommendation on depression screening to specifically recommend screening during the pre- and postpartum periods. While practitioners in high-income countries can respond to this new recommendation by implementing one of several existing depression screening tools developed in Western contexts, such as the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire-9 (PHQ-9), these tools lack strong evidence of cross-cultural equivalence, validity for case finding, and precision in measuring response to treatment in developing countries. Thus, there is a critical need to develop and validate new screening tools for perinatal depression that can be used by lay health workers, primary health care personnel, and patients.

Methods

Working in rural Kenya, we used free listing, card sorting, and item analysis methods to develop a locally-relevant screening tool that blended Western psychiatric concepts with local idioms of distress. We conducted a validation study with a random sample of 193 pregnant women and new mothers to test the diagnostic accuracy of this scale along with the EPDS and PHQ-9.

Results

The sensitivity/specificity of the EPDS and PHQ-9 was estimated to be 0.70/0.72 and 0.70/0.73, respectively. This compared to sensitivity/specificity of 0.90/0.90 for a new 9-item locally-developed tool called the Perinatal Depression Screening (PDEPS). Across these three tools, internal consistency reliability ranged from 0.77 to 0.81 and test-retest reliability ranged from 0.57 to 0.67. The prevalence of depression ranges from 5.2% to 6.2% depending on the clinical reference standard.

Conclusion

The EPDS and PHQ-9 are valid and reliable screening tools for perinatal depression in rural Western Kenya, the PDEPS may be a more useful alternative. At less than 10%, the prevalence of depression in this region appears to be lower than other published estimates for African and other low-income countries.

Introduction

Depression is a leading cause of disability worldwide, yet access to timely assessment and treatment is very limited in many low-income settings, especially in rural communities. Depression affects men and women, young and old, but women who experience depression during pregnancy or in the year after childbirth are a particularly underserved population. The prevalence of perinatal depression among women living in poor countries ranges widely, possibly exceeding 30% in rural settings (Villegas et al., 2011).

Depression among pregnant women and new mothers has been linked to increased maternal morbidity and mortality (Oates, 2003, Khalifeh et al., 2016), poor infant health (Field et al., 2004, Rahman et al., 2016, Grigoriadis et al., 2013, Surkan et al., 2016, Gelaye et al., 2016), and poor early childhood outcomes—such as developmental, cognitive, and emotional delays (Beck, 1998, Junge et al., 2017, Gentile, 2017)—making it a significant public health concern. Few public health systems currently have the resources to treat perinatal depression, but recent work has shown that cognitive behavioral interventions delivered by lay health workers are efficacious (Rahman et al., 2008, Joshi et al., 2014). Before such treatments can be delivered at scale, however, it is essential to overcome many barriers, including barriers to screening for depression.

Routine screening for perinatal depression is not common in most primary health care settings. The U.S. Preventive Services Task Force only recently updated their recommendation on depression screening to specifically recommend screening during the pre- and postpartum periods (Siu and the US Preventive Services Task Force, 2016). While practitioners in high-income countries can respond to this new recommendation by implementing one of several existing depression screening tools developed in Western contexts, such as the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire-9 (PHQ-9), these tools lack strong evidence of cross-cultural equivalence, validity for case finding, and precision in measuring response to treatment in developing countries (Sweetland et al., 2014, Tsai et al., 2013). Thus, there is a critical need to develop and validate new screening tools for perinatal depression that can be used by lay health workers, primary health care personnel, and patients. Our study contributes to this effort by attempting to validate the EPDS and PHQ-9 in rural Kenya, while at the same time developing and validating a new instrument that blends items from existing screening tools with local idioms of distress (Kohrt et al., 2011).

Section snippets

Setting and participants

We conducted this prospective study in Bungoma, Kenya. This rural county is situated in what used to be known as Western Province. When the 2010 Constitution of Kenya was enacted in 2013, 47 counties in a new devolved system of government replaced the existing 8 provinces. Bungoma is one of the largest counties in this new system. It is home to more than 1.6 million residents, nearly half of whom live in poverty (Wiesmann et al., 2014).

We recruited participants for two main study activities:

Participant characteristics

We conducted free listing and card sorting exercises with 2 groups of pregnant women and new mothers (n = 12) and 6 groups of CHVs (n = 38). On average, groups had 6.2 participants (SD = 0.9). The average age of the female clients and CHVs was 28.2 (SD = 3.4) and 41.4 years (SD = 7.8), respectively. 84.2% of CHVs were female, and 55.3% finished secondary school. This compared to 33.3% of the female clients.

Item shortlisting

The 6 groups of CHVs generated a total of 153 cards (25.5 cards per group; SD = 3.2).2

Discussion

This study demonstrates that the EPDS and PHQ-9 screening tools have acceptable sensitivity and specificity for detecting major depressive episode (DSM-5) among pregnant women and new mothers in Kenya. The EPDS diagnostic validity results are at the low end of what is reported in other studies of African samples, and our recommended cutoff of 16 is notably higher that what these other studies report (see Tsai et al., 2013 and Table A8 in the Online Appendix), but our results confirm that the

Acknowledgements

The authors would like to thank Sarah Yussef, Hassan Yussef, Caroline Khwituta, Teresa Kangogo, Mary Ogina, Medina Nyongesa, Eileen Mukonye, Alice Seurey, Maximilla Chivinh, and Everline Walutila for their dedication and hard work in carrying out this study.

Grant funding

This research was supported by a grant from the Duke Global Health Institute (453-0751).

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